Hematometra is a violation of the evacuation of blood from the uterine cavity, leading to its accumulation in the organ. It can develop after childbirth, abortion, intrauterine interventions. Hematometra can be suspected based on a comparison of anamnesis with complaints of sudden cessation of blood flow after intrauterine intervention, a feeling of heaviness and cramping pains in the lower abdomen. Signs of bleeding (tachycardia, hypotension, dizziness, anemia) can be expressed to varying degrees. Hematometra is diagnosed according to the results of vaginal examination, ultrasound, probing of the uterine cavity. At the initial stage, medical stimulation of uterine contractions is performed, with inefficiency – vacuum aspiration, therapeutic hysteroscopy.
Hematometra is a pathological condition that develops due to difficulty or impossibility of outflow of menstrual, postpartum, postabortem bloody discharge from the uterine cavity. Due to the variety of reasons, the true frequency of hematometry is unknown, but in gynecology this pathology is relatively rarely diagnosed. It usually develops in young women. Hematometra can be associated with both organ pathology (congenital anomalies and acquired diseases of the uterus and vagina) and functional causes (inadequate hemostasis and poor contraction of the myometrium). It can be combined with hematosalpinx and hematocolpos; in case of infection of the contents of the uterine cavity, pyometra or other purulent complications develop. In connection with the above, an important aspect is the prevention and timely evacuation of hematometra.
Taking into account possible etiological factors , the following forms of pathology are distinguished:
- hematometra, developed in the postpartum period
- of the hematometra, developed as a result of intrauterine interventions
- hematometra developed due to obstruction of the genital tract
- hematometra developed as a result of cervical canal stenosis
The causes can be congenital, as well as acquired (organic or functional). Congenital anomalies of the development of the genital organs can be represented by atresia of the cervical canal, Asherman syndrome, septate uterus, vaginal atresia. If this pathology was not diagnosed and corrected in childhood, then with the onset of menstrual function, blood may accumulate in the uterine cavity, i.e. a hematometra may form.
Organic causes include various pathological formations of the uterus and the cervical canal, creating mechanical obstacles to the outflow of menstrual blood, bloody discharge after an abortion, and SDC from the uterine cavity. These may be large polyps of the cervical canal, myomatous nodes located near the fallopian pharynx (incl. emerging submucous fibroids), endometrial cancer or cervical cancer. Obturation of the internal pharynx is sometimes caused by a fragment of a fetus destroyed during abortion or a placenta site, a blood clot lingering in the uterine cavity. The formation of a hematometra may be associated with cicatricial stenosis of the cervix due to traumatic surgical interventions, radiation therapy.
The causes of the functional order include spasm of the cervical canal after artificial termination of pregnancy (both medical and medical abortion), therapeutic and diagnostic curettage of the uterine cavity. Hematometra developed in the first weeks after childbirth is called a lochiometer. Most often, this complication occurs against the background of uterine atony in the postpartum period, the cause of which may be weak labor activity, overgrowth of the uterus with a large fetus, manual separation of the afterbirth, hemorrhagic shock, scars on the uterus, etc.
The severity of the clinical symptoms of a hematometra depends on the cause of the pathology, its prescription and the amount of bloody contents accumulated in the uterus. The sudden cessation of blood discharge from the genital tract after childbirth, abortion, and intrauterine manipulations allows you to suspect the formation of a hematometra. With congenital anomalies of the development of the genitals, adolescent girls do not have menstruation; with stenosis of the cervical canal, secondary amenorrhea develops (false form). At the same time, there is a feeling of heaviness and periodically occurring spastic pains in the lower abdomen, which women who have given birth compare with labor pains. Sometimes the pain symptoms are poorly expressed.
Due to the ongoing internal bleeding, there is increasing weakness, arterial hypotension, tachycardia, dizziness, flashing of “flies” before the eyes; sometimes – episodes of loss of consciousness. The presence of blood in the uterine cavity creates conditions for local inflammation (endometritis, metroendometritis) and the development of pyometra. Against the background of an intrauterine infectious process, the pain increases, radiates into the lower back and coccyx; fever, chills appear, the patient’s well-being worsens even more. Untimely evacuation of the hematometra in the future may cause peritonitis, pelvioperitonitis, sepsis, infertility.
The hematometra can be diagnosed by a combination of anamnestic, clinical and instrumental data. At the gynecologist’s consultation, the nature of menstrual function, recent intrauterine interventions, obstetric history are clarified. During vaginal examination, an enlarged uterus of a soft consistency is determined, painful on palpation. Before continuing the diagnostic search, it is necessary to exclude uterine pregnancy, therefore, appropriate tests are prescribed to the patient, ultrasound of the pelvic organs is performed.
The diagnosis of hematometra can be confirmed by probing the uterine cavity: when a probe is inserted through the cervical canal into the uterine cavity, it is possible to obtain blood. During intravaginal ultrasound scanning, liquid contents, blood clots, as well as pathological formations (polyp, uterine fibroids, etc.) are visualized in the uterine cavity. With the help of laboratory tests (smear on the flora, bakposeva), it is possible to obtain data for the infectious process. In cases that are difficult to diagnose, hysteroscopy is performed; it makes it possible not only to determine the cause of hematometra, but also to carry out therapeutic measures.
The main therapeutic task is to eliminate the hematometra, eliminate its causes and create conditions for the possibility of an unhindered outflow of the contents of the uterus. Sometimes it is possible to achieve emptying of the hematometra already in the process of diagnostic probing of the uterine cavity.
With uterine atony, drug stimulation of its contractility is performed by prescribing uterotonic drugs (oxytocin, ergot alkaloids, methylergometrine). If the accumulation of blood in the uterine cavity is caused by cervical spasm, antispasmodics are used (a combination of metamizole, pitofenone and fenpiverinium, drotaverine). NSAIDs and antibiotics are prescribed to prevent inflammatory complications. If complete evacuation of blood is impossible, vacuum aspiration of the contents of the uterine cavity is carried out.
At the next stage of treatment, in order to exclude repeated accumulation of blood, it is necessary to eliminate the cause of hematometra. This is usually required in the presence of anatomical obstacles to the outflow of uterine contents. For this purpose, hysteroresectoscopy can be performed (removal of cervical and uterine polyps, excision of septa, conservative vaginal myomectomy, etc.) or therapeutic and diagnostic curettage (removal of parts of the fetal egg, fragments of the placenta). In complicated cases, removal of the uterus may be required – hysterectomy or supravaginal amputation of the uterus.
Regular preventive examinations will help prevent the occurrence of hematometra and its accompanying complications. To exclude female genital abnormalities, a pediatric gynecologist should examine the girl before puberty, and the absence of menstruation by the age of 16 is a serious reason for an in-depth gynecological examination.
Pregnancy planning, exclusion of abortions, timely treatment of surgical pathology of the pelvic organs, monitoring of intrauterine manipulations, adequate management of childbirth and the postpartum period play an important preventive role. Breastfeeding, frequent urination, applying an ice bubble to the abdomen helps to prevent a postpartum hematometra – these measures improve the contraction of the myometrium and uterine vessels.